Amended in Senate April 21, 2015

Amended in Senate March 26, 2015

Senate Bill No. 137

Introduced by Senator Hernandez

January 26, 2015

An act to add Section 1367.27 to the Health and Safety Code, and to add Section 10133.15 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

SB 137, as amended, Hernandez. Health care coverage: provider directories.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of the act is a crime. Existing law requires a health care service plan to provide a list of contracting providers within a requesting enrollee’s or prospective enrollee’s general geographic area.

Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires insurers subject to regulation by the commissioner to provide group policyholders with a current roster of institutional and professional providers under contract to provide services at alternative rates.

This bill would require health care service plans and insurers subject to regulation by the commissioner for services at alternative rates to make a provider directory available on its Internet Web site and to update the directory weekly. The bill would require the Department of Managed Health Care and the Department of Insurance to develop provider directory standards. By placing additional requirements on health care service plans, the violation of which is a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

The people of the State of California do enact as follows:

SECTION 1.  

Section 1367.27 is added to the Health and Safety
Code, to read:

1367.27.  

(a) (1) A health care service plan shall make
available a provider directory or directories that shall provide
information on contracting providers, including those that accept
new patients, pursuant to the requirements of this section and
Section 1367.26. A provider directory shall not include information
on a provider that does not have a current contract with the plan.

(2) A plan shall provide the directory or directories for the
specific network offered for each product using a consistent method
of network and product naming, numbering, or other classification
method that ensures the public, enrollees, potential enrollees, the
department, and other state or federal agencies can easily identify
which providers participate in which networks for which products.
A health plan shall use the same consistent classification method
in provider contracts and communications to ensure that providers
can identify the products and networks that they are legally
contracted to provide services in. The classification shall be
consistent across plans in order to permit the department and other
state or federal agencies to construct multiplan directories.

(3) The provider directory or directories shall be available on
the plan’s Internet Web site to the public and potential enrollees
without any requirement that a member of the public or potential
enrollee indicate intent to obtain coverage from the plan. The
directory or directories shall be available to the public without
requiring that an individual seeking the directory information
demonstrate coverage with the plan, provide a policy number,
provide any other identifying information, or create or access an
account.

(b) (1) The provider directory or directories shall be accessible
on the plan’s public Internet Web site through a clearly identifiable
link or tab and in a manner that is accessible and searchable by
the public, potential enrollees, enrollees, and providers. The plan’s
public Internet Web site shall allow for provider searches by name,
practice address, National Provider Identification number,
California license, facility or identification number, product, tier,
provider language, medical group, or independent practice
association, hospital, or clinic, as appropriate. If another technology
emerges that takes the place of Internet Web sites, the department
shall direct the plan to make the information required under this
section available on the subsequent technology in a timeframe that
allows for implementation of the technology, not to exceed six
months. The plan shall also make a paper copy of the directory or
directories available upon request.

(2) The plan shall update the provider directory or directories,
at least weekly, pursuant to paragraph (1) with any change to
contracting providers, including all of the following:

(A)  begin delete Instances where end delete begin insert Whether end insert a contracting provider is no longer
accepting new patients, or that the provider moved or relocated
from the contracted service area of the plan, or has retired or has
otherwise ceased to practice.

(B)  begin delete Instances where end delete begin insert Whether end insert the contracting provider group, if
any, has identified that the provider is no longer associated with
the group or is no longer accepting new patients.

(C)  begin delete Instances where end delete begin insert Whether end insert the plan identified a change based
on an enrollee complaint that a provider was not accepting new
patients or was otherwise not available.

(D) Any other relevant information that has come to the attention
of the plan affecting the content of the provider directory.

(3) The provider directory or directories shall include both an
email address and a telephone number for members of the public
and providers to notify the plan if the provider directory
information appears to be inaccurate.

(4) By September 15, 2016, or no later than six months after
the date that provider directory standards are developed under
subdivision (d), a plan shall use the developed standards pursuant
to subdivision (d) for each product offered by the plan.

(c)  A full service health care service plan shall include all of
the following information in the provider directory or directories:

(1) The provider’s name, begin delete location(s) end delete begin insert practice location or
locations end insert , and contact information.

(2) Type of practitioner.

(3) National Provider Identification number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) (A) For physicians, the medical group, if any.

(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, and nurse midwives to the extent their services
may be accessed and are covered through the contract with the
plan.

(C) For federally qualified health centers or primary care clinics,
the name of the federally qualified health center or clinic.

(D) For any provider described in subparagraph (A) or (B) who
is employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the plan, the name of the
provider, and the name of the federally qualified health center or
clinic.

(7) Hospital admitting privileges, if any, for physicians and
other health professionals contracted with the plan whose scope
of services for the plan include admitting patients and who have
admitting privileges at a hospital.

(8) Non-English language, if any, spoken by a health
professional as well as non-English language, if any, spoken by
begin delete staff to the provider. end delete begin insert the provider’s staff. end insert

(9) Whether a provider is accepting new patients with the
product selected by the enrollee or potential enrollee.

(10) Network tier to which the provider is assigned, if applicable.
“Tiered provider network” means a network of participating
providers that has been divided into subgroupings differentiated
by the health plan according to enrollee cost-sharing levels or
quality scores. Nothing in this section shall be construed to require
the use of network tiers other than contract and noncontracting
tiers.

(11) A disclosure that begin delete enrolles end delete begin insert enrollees end insert are entitled to full and
equal access to covered services, including enrollees with
disabilities as required under the Americans with Disabilities Act
and Section 504 of the Rehabilitation Act.

(12) All other information necessary to conduct a search
pursuant to subdivision (b).

(d) A specialized health care service plan shall include all of
the following information for each of the provider directories used
by the plan for its networks:

(1) The provider’s name, begin delete location, end delete begin insert practice location or locations, end insert
and contact information.

(2) Type of begin delete Practitioner end delete begin insert practitioner end insert .

(3) National Provider Identification number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) If participating in a group practice, the name of the group
practice.

(7) The names of any allied health care professionals to the
extent their services are covered through the contract with the plan.

(8) Non-English language, if any, spoken by a health provider
as well as non-English language, if any, spoken by begin insert the provider’s end insert
staff.

(9) Whether a provider is accepting new patients enrolled in the
product that the directory applies to.

(10) A disclosure that enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities as
required under the Americans with Disabilities Act and Section
504 of the Rehabilitation Act.

(e) (1) By March 15, 2016, the department and the Department
of Insurance shall develop provider directory standards for purposes
of paragraph (3) of subdivision (b).

(2) The standards shall be sufficient to permit a single uniform
electronic directory that would allow a member of the public to
determine whether a physician or other provider is available to an
enrollee of the California Health Benefit begin delete Exchange as well as end delete
begin insert Exchange, end insert a beneficiary of the Medi-Cal program enrolled in a
Medi-Cal managed care begin delete plan. The standards shall be sufficient to
permit a single uniform directory that would allow a member of
the public to determine whether a physician or other provider is
available to an enrollee with group coverage as well as to a
beneficiary of the Medi-Cal program enrolled in a Medi-Cal
managed care plan or to an enrollee of the California Health Benefit
Exchange. end delete begin insert plan, as well as to an enrollee with group coverage. end insert

(3) The department and the Department of Insurance shall seek
input from interested parties, including holding at least one public
meeting. In developing the directory begin delete template, end delete begin insert standards, end insert the
department shall take into consideration any requirements for
provider directories established by the federal Centers for Medicare
and Medicaid Services.

(f) (1) The plan shall provide the directory or directories to the
department in a format and manner to be specified by the
department.

(2) The plan shall demonstrate no less than quarterly to the
department that the information provided in the provider directory
or directories is consistent with the information required under
Sections 1367.03 and 1367.035, and other provisions of this
chapter. The plan shall assure that other information reported to
the department is consistent with the information provided to
enrollees, potential enrollees, and the department pursuant to this
section.

(3) The plan shall demonstrate to the department that enrollees
or potential enrollees seeking a provider that is contracted with
the network for a particular product can identify these providers
and that the provider is accepting new patients. The plan shall
ensure that the accuracy of the provider directory meets or exceeds
97 percent.

(4) The plan shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past three months for primary care providers, or six months for
specialty care providers, to determine whether the provider is
accepting patients or referrals from the plan, if claims are paid by
the plan. If claims are not paid by the plan, the plan shall contact
any provider that is listed in the provider directory who has not
submitted encounter data within the past three months for primary
care providers, or six months without encounter data for a specialty
care provider. If the provider does not respond within 30 days, the
plan shall remove the provider from the provider directory. This
requirement does not apply to claims or encounter data from new
primary care providers in the first three months, or new specialty
care providers in the first six months, of the contract.

(g) The plan shall make available an electronic copy of, or upon
request, one physical copy of the provider directory or directories
to the following:

(1) To the State Department of Health Care Services for
Medi-Cal managed care plans.

(2) To the California Health Benefit Exchange for the networks
of the products offered through the California Health Benefit
Exchange, as required by contract.

(3) On request by the Public Employees’ Retirement System,
to the Public Employees’ Retirement System.

(4) The department and the Department of Insurance.

(5) On request by a group purchaser, provider directory or
directories for the products available in the market segment of the
group.

(h) If a contracting provider, or the representative of a
contracting provider, informs an enrollee or potential enrollee that
the provider is not accepting new patients, the contract between
the plan and the provider shall require the provider to begin insert inform the
plan that the provider is not accepting new patients and end insert direct the
enrollee or potential enrollee to the plan for additional assistance
in finding a provider and also to the department to inform it of the
possible inaccuracy in the provider directory. If an enrollee or
potential enrollee informs a plan of a possible inaccuracy in the
provider directory or directories, the plan shall undertake
immediate corrective action to ensure the accuracy of the directory
or directories.

(i) This section does not prohibit a plan from requiring its
contracting providers, contracting provider groups, or contracting
specialized health care plans to satisfy the requirements of this
section. If a plan delegates the responsibility of complying with
this section to its contracting providers, contracting provider
groups, or contracting specialized health care plans, the plan shall
ensure that the requirements of this section are met.

(j) Every health care service plan shall ensure processes are in
place to allow providers to promptly verify or submit changes to
demographic information and participation status. Those processes
shall, at a minimum, include an online interface for providers to
submit verification or changes electronically and shall allow
providers to receive an acknowledgment of receipt from the health
care service plan. Providers shall verify or submit changes to
demographic information and participation status using this process
according to the terms of their contract with the contracted health
plan. begin delete Providers shall verify or submit changes to demographic
information and participation status using this process according
to the terms of their contract with the contracted health plan. end delete

(k) Every health care service plan shall allow enrollees to request
the information required by this section through their toll-free
telephone number, electronically, or in writing. On request of an
enrollee or potential enrollee, the plan shall provide the information
required under subdivisions (a), (b), (c), and (g) in written form.
The information provided in written form may be limited to the
geographic region in which the enrollee or potential enrollee resides
or intends to reside.

SEC. 2.  

Section 10133.15 is added to the Insurance Code, to
read:

10133.15.  

(a) (1) A health insurer that contracts with providers
for alternative rates of payment pursuant to Section 10133 shall
make available a provider directory or directories that shall provide
information on contracting providers, including those that accept
new patients pursuant to the requirements of this section and
Section 10133.1. A provider directory shall not include information
on a provider that does not have a current contract with the insurer.

(2) An insurer shall provide the directory or directories for the
specific network offered for each product using a consistent method
of network and product naming, numbering, or other classification
method that ensures the public, begin delete enrollees, end delete begin insert insureds, end insert potential
begin delete enrollees, end delete begin insert insureds, end insert the department, and other state or federal
agencies can easily identify which providers participate in which
networks for which products. An insurer shall use the same
consistent classification method in provider contracts and
communications to ensure that providers can identify the products
and networks that they are legally contracted to provide services
in. The classification shall be consistent across begin delete plans end delete begin insert products end insert in
order to permit the department and other state or federal agencies
to construct multiplan directories.

(3) The provider directory or directories shall be available on
the insurer’s Internet Web site to the public and potential begin delete enrollees end delete
begin insert insureds end insert without any requirement that a member of the public or
potential begin delete enrollee end delete begin insert insureds end insert indicate intent to obtain coverage from
the insurer. The directory or directories shall be available to the
public without requiring that an individual seeking the directory
information demonstrate coverage with insurer, provide a policy
number, provide any other identifying information, or create or
access an account.

(b) (1) The provider directory or directories shall be accessible
on the insurer’s public Internet Web site through a clearly
identifiable link or tab and in a manner that is accessible and
searchable by the public, potential begin delete enrollees, enrollees, end delete begin insert insureds,
insureds, end insert and providers. The insurer’s public Internet Web site
shall allow for provider searches by name, practice address,
National Provider Index number, California license number, facility
or identification number, product, tier, provider language, medical
group, or independent practice association, hospital, or clinic, as
appropriate. If another technology emerges that takes the place of
Internet Web sites, the department shall direct the insurer to make
the information required under this section available on the
subsequent technology in a timeframe that allows for
implementation of the technology, not to exceed six months. The
insurer shall also make a paper copy of the directory or directories
available upon request.

(2) The insurer shall update the provider directory directories,
at least weekly, posted pursuant to paragraph (1) with any change
to contracting providers, including all of the following:

(A)  begin delete Instances where end delete begin insert Whether end insert a contracting provider has notified
the insurer that the provider no longer begin delete intents end delete begin insert intends end insert to participate
as a contracting provider, is no longer accepting new patients, that
the provider moved or relocated from the contracted service area
of the begin delete plan, end delete begin insert product, end insert or has retired or otherwise ceased to practice.

(B)  begin delete Instances where end delete begin insert Whether end insert the contracting provider group, if
any, has identified that the provider is no longer associated with
the group or is no longer accepting new patients.

(C)  begin delete Instances where end delete begin insert Whether end insert the begin delete plan end delete begin insert insurer end insert identified a change
based on begin delete an enrollee end delete begin insert an insured end insert complaint that a provider was not
accepting new patients or was otherwise not available.

(D) Any other relevant information that has come to the attention
of the begin delete plan end delete begin insert product end insert affecting the content of the provider directory.

(3) The provider directory or directories shall include both an
email address and a telephone number for members of the public
and providers to notify the insurer if the provider directory
information appears to be inaccurate.

(4) By September 15, 2016, or no later than six months after
the date that provider directory standards are developed under
subdivision (d), an insurer shall use the developed standards
pursuant to subdivision (d) for each product offered by the insurer.

(c) The insurer shall include all of the following information in
the provider directory or directories:

(1) The provider’s name, begin delete location, end delete begin insert practice location or locations, end insert
and contact information.

(2) Type of practitioner.

(3) National Provider Identification number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) (A) For physicians, the medical group, if any.

(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, and nurse midwives to the extent their services
may be accessed and are covered through the contract with the
insurer.

(C) For federally qualified health centers or primary care clinics,
the name of the federally qualified health center or clinic.

(D) For any provider described in subparagraph (A) or (B) who
is employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the begin delete plan, end delete begin insert insurer, end insert the name of
the provider, and the name of the federally qualified health center
or clinic.

(7) Hospital admitting privileges, if any, for physicians and
other health professionals contracted with the insurer whose scope
of services for the begin delete plan end delete begin insert product end insert include admitting patients and who
have admitting privileges at a hospital.

(8) Non-English language, if any, spoken by a health
professional as well as non-English language, if any, spoken by
begin delete staff to the provider. end delete begin insert the provider’s staff. end insert

(9) Whether a provider is accepting new patients with the
product selected by the begin delete enrollee end delete begin insert insured end insert or potential begin delete enrollee. end delete
begin insert insured. end insert

(10) Network tier that the provider is assigned to, if applicable.
“Tiered provider network” means a network of participating
providers that has been divided into subgroupings differentiated
by the insurer according to begin delete enrollee end delete begin insert insured end insert cost-sharing levels or
quality scores. Nothing in this section shall be construed to require
the use of network tiers other than contracting and noncontracting
tiers.

(11) A disclosure that insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the Americans with Disabilities Act and Section
504 of the Rehabilitation Act.

(12) All other information necessary to conduct a search
pursuant to subdivision (b).

(d) A specialized insurer shall include all of the following
information for each of the provider directories used by the insurer
for its networks:

(1) The provider’s name, begin delete location(s) end delete begin insert practice location or
locations end insert , and contact information.

(2) Type of practitioner.

(3) National Provider Identification number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) If participating in a group practice, the name of the group
practice.

(7) The names of any allied health care professionals to the
extent their services are covered through the contract with the begin delete plan. end delete
begin insert insurer. end insert

(8) Non-English language, if any, spoken by a health
professional as well as non-English language, if any, spoken by
begin delete staff. end delete begin insert the provider’s staff. end insert

(9) Whether a provider is accepting new patients enrolled in the
product that the directory applies to.

(10) A disclosure that insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the Americans with Disabilities Act and Section
504 of the Rehabilitation Act.

(e) (1) By March 15, 2016, the Department of Managed Health
Care and the department shall develop a provider directory
standards for purposes of paragraph (3) of subdivision (b).

(2) The standards shall be sufficient to permit a single uniform
electronic directory that would allow a member of the public to
determine whether a physician or other provider is available to an
begin delete enrollee end delete begin insert insured end insert of the California Health Benefit begin delete Exchange as well
as end delete begin insert Exchange, end insert a beneficiary of the Medi-Cal program enrolled in
a Medi-Cal managed care begin delete plan. The standards shall be sufficient
to permit a single uniform directory that would allow a member
of the public to determine whether a physician or other provider
is available to an enrollee with group coverage as well as to a
beneficiary of the Medi-Cal program enrolled in a Medi-Cal
managed care plan or to an enrollee of the California Health Benefit
Exchange. end delete begin insert plan, as well as to an insured with group coverage. end insert

(3) The department and the Department of Managed Health
Care shall seek input from interested parties, including holding at
least one public meeting. In developing the directory begin delete template, end delete
begin insert standards, end insert the begin insert department and the end insert Department of Managed Health
Care shall take into consideration any requirements for provider
directories established by the federal Centers for Medicare and
Medicaid Services.

(f) (1) The insurer shall provide the directory or directories to
the department in a format and manner to be specified by the
department.

(2) The insurer shall demonstrate no less than quarterly to the
department that the information provided in the provider directory
or directories is consistent with the information required under
Section 10133.5 and other provisions of this part. The insurer shall
assure that other information reported to the department is
consistent with the information provided to begin delete enrollees, end delete begin insert insureds, end insert
potential begin delete enrollees, end delete begin insert insureds, end insert and the department pursuant to this
section.

(3) The insurer shall demonstrate to the department that begin delete enrollees end delete
begin insert insureds end insert or potential begin delete enrollees end delete begin insert insureds end insert seeking a provider that is
contracted with the network for a particular product can identify
these providers and that the provider is accepting new patients.
The insurer shall ensure that the accuracy of the provider directory
meets or exceeds 97 percent.

(4) The insurer shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past three months for primary care providers, or six months for
specialty care providers, to determine whether the provider is
accepting patients or referrals from the begin delete plan, end delete begin insert insurer, end insert if claims are
paid by the insurer. If the provider does not respond within 30
days, the insurer shall remove the provider from the provider
directory. This requirement does not apply to claims or claim data
from new primary care providers in the first three months, or new
specialty care providers in the first six months, of the contract.

(g) The insurer shall make available an electronic copy of, or
upon request, one physical copy of the provider directory or
directories to the following:

(1) To the State Department of Health Care Services for
Medi-Cal managed care plans.

(2) To the California Health Benefit Exchange for the networks
of the products offered through the California Health Benefit
Exchange, as required by contract.

(3) On request by the Public Employees’ Retirement System,
to the Public Employees’ Retirement System.

(4) The department and the Department of Managed Health
Care.

(5) On request by a group purchaser, provider directory or
directories for the products available in the market segment of the
group.

(h) If a contracting provider, or the representative of a
contracting provider, informs an begin delete enrollee end delete begin insert insured end insert or potential
begin delete enrollee end delete begin insert insured end insert that the provider is not accepting new patients,
the contract between the insurer and the provider shall require the
provider to begin insert inform the insurer that the provider is not accepting
new patients and end insert direct the begin delete enrollee end delete begin insert insured end insert or potential begin delete enrollee end delete
begin insert insured end insert to the insurer for additional assistance in finding a provider
and also to the department to inform it of the possible inaccuracy
in the provider directory. If an begin delete enrollee end delete begin insert insured end insert or potential begin delete enrollee end delete
begin insert insured end insert informs an insurer of a possible inaccuracy in the provider
directory or directories, the insurer shall undertake immediate
corrective action to ensure the accuracy of the directory or
directories.

(i) This section does not prohibit an insurer from requiring its
contracting providers, contracting provider groups, or contracting
specialized health care plans to satisfy the requirements of this
section. If an insurer delegates the responsibility of complying
with this section to its contracting providers, contracting provider
groups, or contracting specialized health care plans, the insurer
shall ensure that the requirements of this section are met.

(j) Every insurer shall ensure processes are in place to allow
providers to promptly verify or submit changes to demographic
information and participation status. Those processes shall, at a
minimum, include an online interface for providers to submit
verification or changes electronically and shall allow providers to
receive an acknowledgment of receipt from the health insurer.
Providers shall verify or submit changes to demographic
information and participation status using this process according
to the terms of their contract with the insurer.

(k) Every health insurer shall allow begin delete enrollees end delete begin insert insureds end insert to request
the information required by this section through their toll-free
telephone number, electronically, or in writing. On request of an
begin delete enrollee end delete begin insert insured end insert or potential begin delete enrollee, end delete begin insert insured, end insert the insurer shall
provide the information required under subdivisions (a), (b), (c),
and (g) in written form. The information provided in written form
may be limited to the geographic region in which the begin delete enrollee end delete
begin insert insured end insert or potential begin delete enrollee end delete begin insert insured end insert resides or intends to reside.

SEC. 3.  

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.